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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200020
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:20:50 PM

Document Has Been Signed on 05/22/2024 04:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:GOOD SAMARITAN RESIDENTIAL CARE FACILITYFACILITY NUMBER:
019200020
ADMINISTRATOR/
DIRECTOR:		FRANKLIN E. BAUTISTAFACILITY TYPE:
735
ADDRESS:275 JACKSON STREETTELEPHONE:
(510) 886-1821
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Ellen Jovero, StaffTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct an annual required inspection and were met by caregiver Ellen Jovero. Administrator was informed via telephone about the purpose of visit. The facility is a Level 4i home vendorized by the Regional Center of the East Bay (RCEB). There were clients at the facility upon arrival.

Facility has an approved fire clearance for 6 ambulatory residents. LPA inspected the facility inside and out including but not limited to client rooms, bathrooms, kitchen, dining area, laundry room and backyard. Hot water measured at 109.9 degrees Fahrenheit. Hallways and passageways were free of obstruction. There was sufficient supply of perishable and non-perishable foods. Hygiene and hygiene products were available for the clients. There was supply of warm blankets, towels and sheets observed. There were no bodies of water observed. Chemicals and other toxic products were locked in a shed in the backyard. Knives and other sharp objects were locked in the office. Fire extinguisher appeared full and was purchased on 5/14/24. Last fire drill was conducted on 4/2/2024.

Due to time limitation LPA will return to continue the annual inspection...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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